Wednesday, April 21, 2010

The Dark Side of EHRs

Sir Cyril Chantler noted, "medicine used to be simple, ineffective and relatively safe; now it is complex, effective and potentially dangerous." His quote was from a Lancet article in 1999 - much before EMRs were being used regularly. I wonder what he would say now!

I blogged back in February about the FDA's consideration of regulating EMRs... and a series of recent stories have come out reminding us of the unintended consequences of using information technology in healthcare… the truth being that problems occur due to a combination of issues, including;
Implementation problems, such as forcing through awkward workflows.
Technical problems, such as failed integration, slow speeds, system outages and true errors in the system design (e.g. 1 + 1 = 3).
Usability problems, such as difficult to read screens, which can affect speed and judgment. Something I've been commenting on a lot in the past year, as in blogs of April, 2009 and August, 2009.

Here are two interesting stories from the Huffington Post Investigative Fund (a new nonpartisan nonprofit dedicated to in-depth reporting):
As Doctors Shift to Electronic Health Systems, Signs of Harm Emerge : A device that is central in the shift toward electronic medical records systems has been linked to instances of death or injury, according to an Investigative Fund review of Food and Drug Administration data.

Amid Digital Records Surge, a Lack of Policing by the FDA: As federal officials encourage the rapid expansion of electronic medical records to help doctors improve care and cut costs, they lack a reliable and systematic method for tracking the safety of these products, agency data and audits show.

Finally, my friend Dale Sanders, a well-known healthcare CIO, wrote an excellent blog bringing the personal touch and common sense thoughts to this topic of Patient Safety and EHRs.
I love this quote: Remember when safety belts in automobiles first became popular? They were simple lap belts, no shoulder strap. Did they aid passenger safety? Yes, in some ways… but they also introduced the danger of a whole new range of injuries, such as lumbar separation and paralysis, which hadn’t previously existed. It wasn’t until we added shoulder straps and the three point anchor to seat belts in cars that the evidence of benefit to passenger safety became clear and without question. We need pause now and add shoulder straps to EHRs.

If you are interested in searching the FDA's database for HIT problems, or submit one of your own, you can do so at MAUDE (Manufacturer and User Facility Device Experience)

With all that said, this should not stop the forward march of EMRs and HIT from helping us improve the quality and efficiency of healthcare... but it should certainly remind us that we are FAR from our ultimate destination and we all (vendors and users) have to figure out how to build, implement and use these systems better and better...

Other stories and articles
NY Times article (April, 2010) on how EMRs in the exam room can provide so much info that it pushes a doctor into “cognitive overload”

The Extent and Importance of Unintended Consequences Related to Computerized Provider Order Entry (JAMIA, 2007)

Overdependence on Technology: An Unintended Adverse Consequence of Computerized Provider Order Entry (AMIA Conference, 2007)

The unintended consequences of computerized provider order entry: Findings from a mixed methods exploration (Intl J of Med Informatics, 2009)

Rush to Electronic Health Records Could Increase Liability Risk
(Insurance Journal, June, 2010) which references this paper:
E-Health Hazards: Provider Liability and Electronic Health Record Systems

Nov, 2011: has been created in collaboration with medical professional insurance carriers and adverse event reporting and government experts to improve EHR and patient safety and help to reduce professional liability. EHR event reports will be provided to participating EHR vendors and kept confidential by PDR Secure™.  Information from the PDR Secure PSO may be used by medical professional insurance carriers and the FDA to better understand EHR events and to develop education materials that will increase patient safety and benefit physicians and other clinicians in their use of EHR technology.


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  2. Lyle,
    Thanks. I picked up several new insights from your post. Of course, EHRs are only one area in our society that is experiencing new decision support with unintended or odd "side effects."

    Most recently, I used my GPS to get me to and from a meeting in DC from my home in suburbia. The GPS did not recommend the clearly shortest and fastest route (which I actually took, over-riding the GPS's advice.)

    That happened to be "Canal Road," which is not rated for light trucks and has varying lane usage rules based on time of day.

    My GPS, marketed for cars and light trucks, eliminated Canal Road from consideration, even though it was the best route. It simply eliminated the road from consideration.

    To my complete amazement and bedazzlement, it constructed a non-obvious and very fast route home for me. It required my blind faith for it to pay off, but I trusted it and it did work well.

    Decision support in the real world can quickly become so multi-factorial that it can become nearly impossible to vet its advice in real time. Occasionally it's dead wrong. Occasionally it's inexplicably correct. Add in realtime traffic, weather and preference data and it gets both brilliant and maddening. You really have to trust that it knows better than you can. {Reminds me of the scene in an Indiana Jones movie where Harrison Ford steps off a cliff; the bridge appears only after committing to faith in its invisible existence.}

    In short, if we're able to perfect EHRs through the judicious use of shoulder straps (or the abstraction's equivalent), we'll all be surprised. I do agree with your close above, "with all that said" ... we will have better quality, better health care access and value with these systems than without.